Vesico-vaginal fistulas are rare in pediatric populations, with an estimated incidence of approximately 0.1 to 0.2 per 1,000 live births.
They are predominantly congenital and often associated with other urogenital and genital malformations. Urogenital tract anomalies, such as ureteral ectopia or malposition, frequently coexist with structural abnormalities of the genital tract, complicating diagnosis and treatment.

We present the case of a 14-year-old girl who exhibited involuntary urine leakage through the vagina, quantified at about 80 ml following previous surgical treatment of an apparently right ureterocele. She had a complex urogenital syndrome consistent with Herlyn-Werner-Wunderlich syndrome, characterized by uterus didelphys, a septate vagina, right hydrocolpos, and hypoplasia of the right kidney, confirmed through scintigraphy and MRI. Her medical history included two prior surgeries in other hospital: endoscopic incision of what at the moment seemed to be a right ureterocele and hemivaginal incision for hydrocolpos, with further laparoscopic, cystoscopic, and vaginoscopic exploration with the incision of the right hemivagina. Diagnostic assessments comprised uro-MRI, pelvic MRI, mictional urethrocystography, and renal scintigraphy.

In our departament we performed an endoscopic exploration of the bladder and vagina that revealed a vesico-uretero-vaginal fistula
originating at the bladder incision site. The wide opening previously created enabled the comunication of the right ureter - bladder-
and right hemyvagina. The communication has been confirmed by methylene blue testing during wich blue dye was observed to
have pased in the right hemyvagina. We performed a robotic approach that enabled us to visualize the uterine didelphys, with each
uterus having its own fallopian tube and attached ovary. To better identify the right ureter, we used a dual approach: we performed a ureteroscopy, and the light from the scope guided us in locating the ureter. Once the ureter was identified and dissected at its cranial
end, we found a hypoplastic kidney located at the level of the iliac vessels, with several small associated vessels. Following this, the caudal dissection of the ureter led us to the fistula site. Through a cystostomy, we were able to excise the fistulous tract, after which
we performed separate closures of the right hemivagina and the bladder. Intraoperative testing verified the watertight closure of the bladder. The operative time 165 min, blood looss - insignificant. Postoperative recovery was uneventful; the urethral catheter was
maintained for two weeks. Follow-up showed no urinary incontinence.

Robotic-assisted surgery enabled precise dissection, fistula excision, and successful reconstruction in complex urogenital malformations.

Continence 19S (2026) 102602
DOI: 10.1016/j.cont.2026.102602